Web Exclusive

Baker was unusually calm as we spoke about his impending death. During my prior visits as his hospice social worker, when the subject had come up, he became anxious.

I asked what was different, and he shared a memory. He was a young man working at a military hospital in England during World War II. He'd been carrying wounded men on stretchers all day in the winter cold—moving those who were still alive from rail cars to operating tables as quickly as possible. His arms were aching; his hands numb.

"I was carrying this poor guy when my arms gave out, and I dropped him on the ground." He wiped away tears, "His intestines oozed out, steaming in the freezing air as he died."

That night, as Baker tried to muffle the sound of his sobs, a figure translucent with light appeared at the foot of his cot. The spectral visitor looked like a young man wearing a World War I uniform with "one of those funny doughboy helmets." Baker felt a wave of peace and love emanating from the figure, "connecting me to something beyond the war and the killing and dying."

The visitor returned throughout the rest of the war, bringing comfort and consolation, and then disappeared. "He's back," Baker said, his voice infused with emotion. "Came to me last night when I was afraid of dying. Afterward, I felt better." I asked what message the figure had brought and he said, "The message is that I'm safe. There's nothing to worry about."

Transpersonal Experiences
Though there's debate about the origins of transpersonal experiences (TEs) such as these, in the last decades there has been a growing body of research—mostly in acute medical and end-of-life settings—attempting to identify their characteristics, prevalence, and meaning. The most thoroughly studied of these phenomena are near-death experiences (NDEs) that appear to occur in roughly 20% of people who have had a close brush with death. Though details of individual experiences vary, common features of NDEs include a sense of leaving one's physical body, feeling movement, experiencing a transmaterial realm often described as peaceful and filled with light, and interacting with deceased loved ones or other beings. There may also be a panoramic life review in which one's life "flashes" before one's eyes, and the sensation of returning to one's body.

Beyond NDEs, a wider range of TEs has been identified, encompassing the kind of paranormal visitation reported by Baker. These also include deathbed visions and after death communication where deceased loved ones appear to those who are dying or grieving; out of body experiences, sudden states of expanded or "unitive" consciousness; and deathbed synchronicities (e.g., clocks or other electronics stopping or starting at the moment of death, synchronistic occurrences in the natural world, or sensing loved one's presence at the time of their death even though they are far away).

Prevalence estimates vary, but these kinds of events appear to be common at the end of life. Although war may seem to stand in opposition to the kind of peace and love that Baker experienced, given combat's life-threatening nature, it's not surprising that these experiences have also been documented among combat veterans.

Staying Silent
Diane Corcoran, PhD, former president of the International Association for Near-Death Studies, credits her time as a nurse during the Vietnam War for her interest in TEs. She says, "I came to believe that many soldiers were having near-death experiences as bombs exploded and gunfire nearly took their lives."

Although these experiences often bring comfort, peace, or joy, research suggests many who experience them are hesitant to talk about it. Holden, Kinsey, and Moore (2014), for example, found that many remain silent out of fear that they will be "dismissed, diagnosed with a mental disorder, or demonized."

Pressures on veterans to remain silent may be even greater. Focusing on these events when they occur in a combat zone could be a dangerous distraction and undermine one's vigilance. That could get a soldier or one of their buddies killed. The value placed by the military on stoicism, uniformity, and rigid norms could discourage disclosing such experiences. Bill Vanderbush, an Army veteran who had an NDE in Vietnam, points out that people don't talk about NDEs because "they are afraid others will think they are crazy or weak. Veterans don't want to come across as being weak" (Kime, 2015).

Research
In one of the few studies on NDEs in veterans, Goza, Holden, and Kinsey (2014) suggest that combat vets are less likely than others to report these experiences. Veterans, they note, are apt to harbor "fears of repercussions from disclosing their experiences including loss of active duty status, unwanted or unnecessary treatment with medication, and [psychiatric] diagnoses."

Very little research has been done specifically on TEs in veterans, and the scant exceptions have focused on NDEs. These studies suggest that approximately 25% of veterans report having had an NDE. Given the fear of stigmatization and pressures to keep quiet, such estimates may be low (Goza, Holden, & Kinsey; Sullivan, 1984).

I've worked with many veterans who were tight-lipped about these experiences throughout their lives but who shared combat-related TEs as death approached. Calvin had been wounded during the Vietnam War. By the time he was airlifted out, he was near death. He remembered going in and out of consciousness as the helicopter rushed him away from the combat zone. At one point the only thing he was aware of was the rhythmic sound of helicopter blades spinning. Suddenly, "the chopper blades turned into giant wings," and he was transported "to heaven, where I felt the deepest love I'd ever known." He met deceased loved ones who helped him review his life, and told him he would survive the war before "sending me back."

During World War II, Jack had barely survived the invasion of Normandy and subsequent push into Germany. In the war's aftermath, he and a friend found themselves in a bombed-out town in France where a woman gave them an apple pie. "The place smelled like death, so I have no idea where on earth those folks got the ingredients for that pie," he recalls, "but as I ate it I had the strangest experience of my life. The normal world just dissolved and my spirit left my body so that I was watching myself from above. I knew I was part of everything and everyone that had ever existed. We were all one, all part of the same spirit." He recalls feeling love for everything and everyone, even German soldiers. The world around him became vibrant with life and energy, and "I could see everything glowing with light."

Triggers and Revelation
Why these experiences emerged after decades of silence as Calvin and Jack neared death is an open question. Approaching death can raise intense existential and spiritual questions about the meaning of life or the nature of mortality—what it's all about, whether there's an afterlife, what one has learned in one's life journey. Maybe such questions naturally bring to mind experiences of the transpersonal and overcome fears of disclosing them.

During the process of life reflection and looking back that can occur at the end of life, memories of TEs may emerge as especially vivid and stir a desire to share or process their meaning. The impact of disease progression, need for medical care, and proximity to death may mimic conditions under which the original TE took place, thereby triggering memories. In some instances, these conditions may even result in new TEs far from the battlefield, as they did with Baker.

Another possibility is that social workers specializing in end-of-life care are particularly attuned to these experiences and adept at creating opportunities for therapeutic conversation and exploration. Perhaps the kinds of conversations that occur when death is near or has been narrowly averted are more amenable to transpersonal themes.

Maybe it's simply that these experiences are often comforting and transformative, thus valuable amidst a sea of end-of-life stressors. People who have experienced TEs often credit them with the development of qualities such as empathy, compassion, or a greater sense of meaning and appreciation for life. Some find that these experiences help them cope with adversity or decrease fear of death.

Therapeutic Benefits
Since TEs typically coincide with life-threatening situations, some veterans who have had them will be grappling with concurrent challenges such as PTSD, moral injury, survivor guilt, or traumatic bereavement. Though these issues may seem to supersede a focus on the transpersonal dimension, such a focus can actually be very therapeutic (Burton, 2017; Christopherson, 2016). For example, Paul was plagued by nightmares about the Korean War and had persistent self-castigating beliefs about being a "bad person" and 9fear of going to hell. During one of our counseling sessions he mentioned that he'd had an NDE after being knocked unconscious by an explosion during the war. He recalled going to a beautiful place of peace and interacting with an "angel." When he began to internalize this being's expressions of love and reassurance, rather than dismissing them as he had been doing, the nightmares ceased and his shame and anxiety diminished.

In addition to the positive benefits above, there are other reasons for social workers serving veterans to inquire about whether a veteran, particularly one who has been to war, has had such experiences. Many will have hidden these memories away, afraid of being dismissed, ridiculed, or labeled as crazy. Others may harbor unspoken concerns that they "cracked up under pressure" as one veteran put it. Sharing such experiences in a supportive relationship where they can be normalized can be helpful.

Goza, Holden, and Kinsey affirm the potential benefits to veterans who've had TEs of disclosing them to helping professionals such as social workers, provided they know how to respond. "One implication," they note, "is that military health care providers need more training. Such training may need to include how to invite survivors of a close brush with death to disclose a possible NDE. It also may need to include the point that NDEs alone do not justify diagnosis of mental disorder nor treatment with psychoactive medication."

Recommendations
Unfortunately, many social workers have received little or no training in these matters. Some may even have interpretive models of understanding that can cause harm if superimposed on a veteran's experience. For example, by psychopathologizing these experiences or dismissing them out of hand as delirium or wishful thinking.

Become familiar with the range and characteristics of these phenomena. There are many resources. The International Association of Near-Death Studies, for example, has general information, as well as content specific to veterans.

Be attentive for opportunities to inquire and foster discussion. Although not everyone will want to talk, and it's important to respect a veteran's preference, don't be afraid to ask. The following are some examples of open-ended questions that may be helpful:

• "Did you ever have any usual experiences during the war—something you couldn't explain that kind of stuck with you?

• "Did you ever have a close brush with death? If so, what do you remember?

• "Did you ever have any vivid dreams or unusual experiences related to the death of a buddy?"

Be prepared to provide basic education about TEs when veterans are interested and receptive. Information can go a long way to normalizing these experiences and easing any sense of isolation. It can be reassuring to know that these events are common during war and that those who experience them are not weak, flawed, or crazy.

Allow the veteran to decide what the experience means. Most people report feeling comforted by these experiences. Where this is the case, TEs can be validated and explored as a source of meaning, wisdom, strength, and/or personal growth. For some, TEs can be distressing and may conflict with one's world view, sense of self, or religious beliefs. When this is the case, be prepared to help process and gain perspective.

Don't impose interpretations such as automatically attributing an experience to something physiological (e.g., delirium, anoxia, hypercarbia, endorphins, disease effects), pharmacological (e.g., medications side effects, substance use), or psychological (e.g., wishful thinking, reactive psychosis, depersonalization, acute dissociation). Though assertive claims are sometimes made by proponents of these hypotheses, none have been proven. Some evidence suggests that one or more of these may be at work, but there is also evidence that suggests the possibility that consciousness survives death (Kelly & Kelly, 2010; Fenwick & Fenwick, 2008). Unless a veteran wants to discuss these matters, don't get distracted by the debate over causation; focus on what the experience means to the veteran.

More research into veteran's TEs is needed not only to identify the range, characteristics, and themes but also to better understand the potential value these events may have within the context of social work practice. Given the widespread lack of knowledge and awareness, veterans often carry memories of these experiences in isolation for fear of judgement, ridicule, or rejection. Social workers working with veterans at any point in the life span are in a position to send messages of openness, trustworthiness, and compassion to veterans who may be looking for someone with whom to share and process the story.

— J. Scott Janssen, MSW, LCSW, is a social worker with the Hospice and Palliative Care Center of Alamance-Caswell in Burlington, NC.